Piriformis Syndrome After Hip Replacement

Rate Limiting Step For Thr Recovery Regardless Of Approach

As has been noted, most hip components are implanted in a cement-less fashion, allowing the bone to heal directly to the implant. This biologic fixation has the major advantage of eliminating loosening as a late failure mechanism. Once the bone has healed to the implant, loosening will not occur even after decades of use . However, the rate limiting step in recovery from hip replacement surgery, be it via an Anterior or Posterior Approach, is the 6-8 weeks it takes the bone to heal to the implant. If a patient pushes a recovery too vigorously in the early weeks post op, implant micromotion leading to loosening and further surgery can occur. REGARDLES OF THE SURGICAL APPROACH.

Hip Arthroplasty And Piriformis Syndrome

This particular patient has had a total hip arthroplasty and the pathology in piriformis syndrome is primarily compression of the sciatic nerve by the piriformis muscle. When you have a hip replacement, they will often disconnect the piriformis muscle, and then when theyre done putting the new hip in they will try and reconstruct that muscle to the femur bone and oftentimes that can cause pressure on the sciatic nerve.

The alternative option is to just not worry about the piriformis muscle. Its not really an important muscle, you can do well without it, and so theyll just not worry about reconstructing it and that can cause the muscle to settle down and scar down and wrap around the sciatic nerve itself, which can be a problem too. Not everybody who has a hip replacement gets these problems but its certainly something to consider after a hip replacement and somebody comes back with sciatica pain.

Treatment Of Piriformis Syndrome

Treatment of piriformis syndrome includes: physical therapy, osteopathic manual therapy, chiropractic adjustments, acupuncture, ice, and anti-inflammatory medication.

Once the physical therapy or other treatment is complete, there is no guarantee the piriformis muscle will stay out of trouble permanently. Piriformis syndrome is a chronic condition and patients are at a high risk of relapse. For this reason, regular piriformis-specific exercises should be mandatory.

Surgical intervention is usually only a last resort, as more than 79 percent of patients with piriformis syndrome report seeing symptom reduction through physical therapy and the use of anti-inflammatory medication.

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How Static Stretching Works

Static stretching is a lengthening technique used to relax and decrease the overactivity of a muscle. Static stretching increases the range of motion allowing the joint to move.

When a joint is free to move, the muscles that move that joint are also free to move it.

To get the most out of static stretching, you want to hold each stretch for 20-30 seconds.

Individuals over 65 years old get better results holding each stretch for up to 60 seconds.

Before we get to the piriformis release, its essential to get familiar with the anatomy of the piriformis

Why does stretching come after self-massage and self-myofascial release?

Simply because we cant release trigger points with stretching, stretching should always come after self-myofascial release.

You want to release any active or latent trigger points before elongating the muscle.

Trigger points dont get released through stretching .

When Should I See My Healthcare Provider For Piriformis Treatment

If you have piriformis syndrome, call your healthcare provider if you experience any of the following:

• Frequent trips or falls because of pain or numbness.
• Pain that lasts longer than a few weeks, especially if youve been following instructions and adjusting your lifestyle.
• Problems controlling your bowels or bladder .
• Sudden, severe pain in your lower back or leg.
• Sudden weakness or numbness in your back or leg.
• Trauma or injury to your back, hip or leg.
• Trouble picking your foot up off the floor.

A note from Cleveland Clinic

Piriformis syndrome occurs when the piriformis muscle presses on the sciatic nerve. The condition can cause pain, numbness or tingling in your butt, hip or upper leg. Most episodes go away in a few days or weeks with rest and simple treatments. But talk to your healthcare provider if an injury led to the pain or if symptoms last more than a few weeks.

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Anatomy Of The Hip Joint

The hip is an important load-bearing joint. Thats why a hip joint that isnt working correctly can cause so much pain and discomfort. The hip joint is where the top of the thigh bone meets a socket inside the pelvis . Ligaments connect the femoral head to the acetabulum. The joint is lined with synovium, a membrane that produces fluid to lubricate the joint and keep it moving smoothly. The joint is cushioned by fluid-filled sacs, or bursae, designed to remove friction between the surrounding muscles, tendons, and bones.

What We Know About Hip Replacement

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References

Rosinsky PJ, Bheem R, Meghpara MB, et al. Asymptomatic Gluteal Tendinopathies Negatively Impact Outcomes of Total Hip Arthroplasty: A Propensity Score-Matched Study. J Arthroplasty. 2021 36:242-249. doi:10.1016/j.arth.2020.07.063

van der Merwe, JM. Metal Hypersensitivity in Joint Arthroplasty. JAAOS. March 2021 5. doi:10.5435/JAAOSGlobal-D-20-00200

Bosker BH, Ettema HB, van Rossum M, et al. Pseudotumor formation and serum ions after large head metal-on-metal stemmed total hip replacement. Risk factors, time course and revisions in 706 hips. Arch Orthop Trauma Surg. 2015 135:417-425. doi:10.1007/s00402-015-2165-2

Gofton W, Beaule PE. Serum Metal Ions with a Titanium Modular Neck Total Hip Replacement System. J Arthroplasty. 2015 30:1781-1786. doi:10.1016/j.arth.2015.04.040

Blizzard DJ, Sheets CZ, Seyler TM, et al. The Impact of Lumbar Spine Disease and Deformity on Total Hip Arthroplasty Outcomes. Orthopedics. 2017 40:e520-e525. doi:10.3928/01477447-20170327-03

Harding P, Holland AE, Delany C, Hinman RS. Do activity levels increase after total hip and knee arthroplasty?. Clin Orthop Relat Res. 2014 472:1502-1511. doi:10.1007/s11999-013-3427-3

Chris Centeno, MD

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Whos Most Likely To Suffer From Piriformis Syndrome

Now going back to whether or not the sciatic nerve goes underneath or through the muscle, those people with an atypical sciatic route through the muscle are more inclined to suffer from piriformis syndrome.

People who sit on hard seats often or for long periods of time, commuters who get pain when sitting and reaching for the pedals, and people with chronic low back pain.

Luckily, there are techniques that we have in place to decrease and reduce the pain caused by piriformis syndrome.

How Long Does Piriformis Syndrome Last

Piriformis syndrome resolves quickly with lifestyle changes and simple treatments. Symptoms often improve in days or weeks.

But the condition tends to come back, especially in people who dont follow their healthcare providers instructions. Severe cases that arent treated properly can greatly reduce a persons ability to function well.

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Buttock And Hip Pain May Include Sciatica Symptoms

If youve ever felt pain in the hip, pain in the center of the buttock, or pain down the back of the leg, you may likely be suffering piriformis syndrome that may cause sciatica symptoms. What is the piriformis muscle? It is located in the buttock region and runs from your sacrum to the outer hip bone . The piriformis muscle works overtime especially in people who are runners. The muscles in and around the gluteal region help with 3 bodily movements:

Woman runner on the beach standing while stretching her knee to her chest. Photo Source: 123RF.com.

Other Causes Of Pain After Hip Replacement

First, watch my video above for some causes of butt pain after hip replacement. Then, please read this extensive review of hip replacement materials and sizing and other things that can go wrong. Heres the abbreviated list of other things that you should consider if youve already had a hip replacement and still have pain:

• An allergy to the hip replacement materials . The cement used or the nickel and/or cobalt used to make the device are common allergies.
• A prosthesis that is too short or long. This will cause a leg length discrepancy.
• Hip pain that was from elsewhere, other than your arthritic hip. That means that the hip pain could have always been referred from the low back or from the SI joint . Hence, replacing the hip joint never treated the original pain generator.
• A pseudotumor . This is a growth caused by irritation of the local tissues due to the hip replacement device.
• Wear particles from a metal-on-metal or minimally invasive anterior hip replacement . This is wear debris that then irritates the tissues and causes pain.

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Reasons Not To Have A Direct Anterior Total Hip Replacement

The direct anterior approach has been around since the early days of hip replacement and is not new. Its popularity waned throughout the 80s, 90s and early 2000s because the posterior approach was considered faster and easier and more applicable to a wider range of hip problems. For complicated cases that may involve congenital deformity or those with prior hardware such as from a previous fracture, the posterior approach offers surgeon an easier ability to extend the incision and dissection if necessary to gain wider exposure.

Around 10 years ago, the direct anterior approach enjoyed a resurgence in the United States when pioneering surgeons, such as Joel Matta, MD, refined modern techniques, instruments and operative tables to facilitate the approach. Proponents of the anterior approach cite that it is more muscle spare and does not require the release of any muscles to gain access to the hip joint. In an age where rapid recovery has become a common buzzword in joint replacement, the idea that this approach could lead to faster return of function resulted in a huge surge in popularity including in the lay press publications like the New York Times and Wall Street Journal. Despite an absence of clinical data proving its merits over other approaches, the purported advantages created a demand for this approach that forced many hip surgeons to adopt it for fear that patients would go elsewhere to find and anterior hip surgeon.

Surgical Techniques The Anterior Vs Posterior Approach

THE POSTERIOR APPROACH: In the posterior approach, the patient is positioned on the side using a standard operating table. The skin incision is over the outside and back of the buttock area. The gluteus muscle is split along the line of its fibers . Small external rotator muscles in the back of the hip are divided . The capsule of the joint is opened, and the femoral head is removed. As opposed to the Anterior Approach where the biggest challenge is dealing with femoral exposure, the trickiest part of the Posterior Approach is exposure of the socket. The key to accurate socket preparation and implant insertion is the initial rigid positioning of the pelvis. And as opposed to the Anterior Approach, femoral shaft access and preparation is straight forward as the surgeon is looking straight down the canal of the femur, thus no special traction or leverage of the femur is necessary.

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Release The Piriformis Muscle

The best way to release the piriformis is by using a massage ball. Below, youll find the full tutorial on how to use the massage ball.

You can control the pressure and easily move around to release the gluteus medius as well.

And, if youre in a lot of pain right now, use the massage ball instead of a foam roller and roll around the piriformis area. Work on the side of your hip, at the top of the glutes and when you feel a tender spot, rest there for 20 seconds.

Youve probably encountered videos online recommending sitting on the roller and performing a deep tissue piriformis release. Ive tried that and it made my pain worse. So please, be cautious with this technique.

I prefer to use the massage ball because you can control the pressure and gently work around the piriformis area.

This helps release the gluteus maximus and gluteus medius, which I find gave me better results. If the piriformis is very sensitive and flaring up, apply very gentle pressure.

If you insist on using the foam roller for self-massage, make sure to start with the hamstrings and quads first, and see how you feel from there.

Many times, working on the hip flexors first can give you great relief.

Place the roller underneath the glutes and gently roll around the piriformis area. Always follow your body and see if this technique works specifically for you.

Paper : Deep Gluteal Syndrome Mini

Seven years after Fillers paper on Piriformis and Related Entrapment Syndromes , Hal Martin and colleagues published this paper that redefined sciatic nerve entrapment as Deep Gluteal Syndrome and described contemporary assessment and management of the condition. These authors suggested that because there are several locations where the sciatic nerve can be entrapped, the term deep gluteal syndrome instead of piriformis syndrome is now preferred. Deep gluteal syndrome is the presence of pain in the buttock caused from non-discogenic and extrapelvic entrapment of the sciatic nerve in the deep gluteal space, beneath the gluteus maximus muscle.

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Effectively Release The Piriformis Muscle

This is a complete piriformis muscle release guide.

I will show you a 3-step process to effectively release the piriformis muscle using self-massage with a massage ball and the foam roller.

Youll also learn when to implement stretching and key tips to follow to avoid making the pain worse.

Below, youll find video tutorials of the release and 9 hip stretches you can include in your recovery. Scroll down to see them!

Dont get overwhelmed. Ill explain everything in simple terms. You just have to follow along!

Piriformis syndrome wont go away? Get the exact recovery plan that helped me fix this pain, and continue to live pain-free for many years without flare-ups.

Static Stretch: Hip Flexors

Kneel on your back leg, bending your front leg 90-degrees. Contract your glutes and shift your body forward. Raise the arm that is on the same side as the knee that is on the ground, stretching to the opposite side until a stretch is felt in the front of your pelvis. Rotate backwards and hold for 30-seconds.

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What Is A Total Hip Replacement

If youve experienced persistent hip pain for months or years, its time for an intervention and an education. Learn about how the hip joint works, the parts of the hip that are injury-prone, and where your hip pain is coming from. Discover the treatments available and determine whether you might be the right candidate for a total hip replacement .

Piriformis Syndrome: A Pain In The Butt

The Piriformis syndrome can be addressed and you do not need to go straight to a hip replacement. Take a second to think about your favorite activity. Youve done it for years, either recreationally or professionally. Lately, the unrelenting pain in your hip has made it difficult to go on. So you end up switching things up-singles tennis to doubles, or from full-court basketball to half court.

Pretty soon, the pain grows so bad that you end up giving up your favorite activity altogether. You dread seeing a specialist because youre concerned that they will say you need a hip replacement. And that will take you out of activity completely, right?

Well, there are other options than a complete hip replacement.

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Why Use A Tshellz Wrap For Your Hip

HEAT is used after you’ve reduced your swelling / inflammation and the sharp pain is less intense . Increasing the temperature in soft tissue will result in increased blood flow circulation as the body sends more blood there to attempt to remove this same heat. It’s the blood in your body that will bring oxygen, nutrients and water to your injured hip to help with healing.

When heat is applied to the hip, veins and blood vessels will start to get bigger to allow more blood flow through to your damaged or torn soft tissue. This in turn relaxes your hip, making the tissue more flexible and elastic. This is why heat is used on older injuries, to loosen tissue and bring in the blood flow needed for soft tissue to repair. Your body will begin to heal itself after it is injured – increasing your blood flow with heat will, in most cases, speed up this natural process – often surprisingly well.

Doctors usually call this process ‘Vasodilation’.

Heat can Make Inflammation, Swelling and Newer Injuries Worse – How?

When we injure ourselves, we start healing right away. The body will naturally raise the temperature at the site of the injury resulting in the inflammatory response . This ‘fake fever’ leaks blood flow to the area to cool it down and start the healing process.

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When Is A Total Hip Replacement Necessary

A total hip replacement, or THR, could be in order in patients with chronic hip pain. Osteoarthritis, rheumatoid arthritis, severe hip injury, or bone tumors are all possible indicators for hip replacement. But because a THR is a complicated and invasive surgery, in which the entire hip is removed and replaced with an artificial joint, it isnt typically the first method of treatment for these conditions. First, your doctor might suggest pain medication, physical therapy, and walking with a cane as forms of treatment. In some cases, your doctor might also recommend a less invasive surgery called an osteotomy to reposition the injured hip joint. But if these methods dont help treat the pain or become less effective over time, further intervention might be needed.

To determine if a THR makes sense for you, your doctor will first order X-rays to look for damage to the hip joint. Its best to perform a total hip replacement only when the possible benefits outweigh the potential risks. In osteoarthritis cases, the University of Maryland Medical Center recommends a total hip replacement only when X-rays show that the hip cartilage has worn away and the bones of the joint are touching. Your doctor will also look for the significant impact of hip pain on your daily life, such as trouble sleeping or an inability to climb stairs.

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